Stayin' Alive

Discussion of public health and health care policy, from a public health perspective. The U.S. spends more on medical services than any other country, but we get less for it. Major reasons include lack of universal access, unequal treatment, and underinvestment in public health and social welfare. We will critically examine the economics, politics and sociology of health and illness in the U.S. and the world.

Monday, March 02, 2015

Sorry for the light posting, been busy. Anyway, a new survey of pediatricians finds that 93% of them say at least one parent asks not to adhere to the recommended schedule of vaccines in a typical month, and 21% say more than 10% of parents make this request. The ostensible point of the published article is that most pediatricians say they accede to this, but I find that baffling. I mean, they have to -- they can't go ahead and inject the kid without the parents' consent.

But obviously, resistance to vaccination is very widespread in the U.S., and I am going to give you the 4-1-1: it is nonsensical. There is no evidence whatsoever, not even suggestive evidence, that giving kids "too many" shots in too short a time is harmful or dangerous in any way. Nor that any given vaccine creates any substantial risk of anything serious for healthy children. This is not controversial, it is not an issue, it is not anything at all other than a mass delusion.

But I find it quite mysterious. There are wackos out there making all sorts of ridiculous claims, but most of them are generally ignored or ridiculed. There are people who claim that cancer is caused by radio waves, but almost nobody declines to use cell phones, even though the assertion got a lot of publicity for a while. Why is this particular version of idiocy so hard to kill?

Thursday, February 26, 2015

Actually it's not Spanish for "difficult," it's Clostridium difficile, an intestinal infection which, take it from me, you want to stay a light year away from. It causes diarrhea which is beyond description, and I know because I had it.

It's been a few years, I think, since I discussed my personal history here, but while George Bush the First was busy bombing Iraq, I was in Beth Israel Medical Center in Boston having my ascending colon removed. It's a long story with many interesting lessons, but it was now almost 25 years ago so some -- though not all -- of the lessons are no longer operative. Anyway, the surgery was unnecessary, I did not in fact have cancer. I would rather still have the ascending colon, however.

I was in the hospital for 11 nights, due to various complications, C. diff being one of them. This is an opportunistic infection that happens when your symbiotic intestinal microbiota gets wiped out by antibiotics. Back then, it was pretty much limited to hospitals and nursing homes, but as the linked report in NEJM says, that's no longer the case. Only about 25% of cases have their origin in hospitals. The authors estimate, based on regional surveillance, that there were 453,000 incident cases in the U.S. in 2011, and 29,000 deaths. That's not a big bar on the cause of death graphic but it's particularly disturbing since it's mostly iatrogenic, and the problem appears to be getting worse.

Again, folks, I cannot emphasize this enough. When you need antibiotics, you may really, really need them. But do not take them if you don't need to. Make sure to have this discussion with your doctor; do not demand antibiotics if your doctor doesn't think you need them. And wash your hands, with soap.

Monday, February 23, 2015

Small town New England is not, for the most part, like other rural areas of the U.S. It's generally relatively affluent -- in fact some towns tend toward upper crust. They often touristy, attracting leaf-peepers, pick-your-own apple fanciers -- maybe there's a nearby ski area or a hiking trail. Also, there are a lot of old houses and antiques and graves of Revolutionary War patriots and that sort of thing, which means they usually have historical societies which own an 18th Century house which is a small museum.

What does that mean? “It means that we believe it is true,” said Debbie Oppermann, the director of the society. “I
know we’re going to get a lot of backlash. We’re going to get
hammered,” she said. “But we have given it an awful lot of thought, and,
based on the evidence we’ve been given, we believe this is a
significant and true event.”

The evidence seems to be that other people reported seeing mysterious flying objects at around that time, and Reed passed a "lie detector" test.

Human credulity, it seems, is limitless. These ant-like creatures traveled for dozens of light years -- a journey of many centuries at the least -- to fly around one small town in New England, abduct members of a single family 3 times, then disappear never to be seen or heard of again. Makes perfect sense to me.

Friday, February 20, 2015

I have occasionally referenced my 20 or more years living in Boston here -- I moved to deepest Connecticut about 4 1/2 years ago. And for my own sake, I am very glad I did. We had some snowy winters while I was there, of course, and they were hard enough to endure.

Boston is an old city which means it has a lot of narrow streets, and unlike, say, New York, most every household has at least one motor vehicle, and most of them park on the street. The transit system was antiquated and creaky even when I lived there, and by now it's apparently relying on bed pans and tube feeding. They've now had what is nearly a record amount of snowfall for an entire winter within four weeks, and no melting in between. People can't get to work, can't shop, can't go to shows, and the economy is starting to collapse. People who were already struggling, who've missed work, are starting to panic about rent and mortgage. I have to wonder about old folks and whether people will start to turn up frozen or starved.

There's rain predicted for Sunday, which will then flash freeze, followed by two more significant snow storms next week. The mayor and governor are warning people to get the snow off their roofs or risk collapse, but how many people have any means of doing that? What if houses do start to collapse all over the city?

My fear is that many people are claiming that this sort of weather pattern will become commonplace due to the decline of arctic sea ice. If this happens again next year, and maybe the year after that, what will become of the city of Boston? What if it goes on into March this year?

Out where I live now, we haven't had quite as much snow, and of course we don't have sidewalks or cars parked on the street or subways to worry about, as long as we can keep our own driveways plowed. (Which is not very easy but I certainly am in no position to complain.) Tomorrow I am going to have to get up on my roof and shovel it off before the rain comes. Chances are I could get away with not doing that but it would be foolish. Of course I'll eventually get too old for that sort of thing but I'll have the money to hire a guy. What about people who don't?

I know, I know, people live in Minnesota and Yellowknife, but they're used to it and they have the infrastructure and the design practices to deal with it. In southern New England, we don't. If this is the new normal, we have big, big problems.

Thursday, February 19, 2015

It has often been aid that the so-called Right to Life movement stops caring about babies as soon as they are born. I've pointed out here many times -- not for a while, I haven't been so international lately as I once was -- that this is obviously true because they never have one word to say about the millions of children under five who die annually. There is, actually, good news however. The Millennium Development Goals (MDG) for child mortality have a target for this year, called MDG 4. It looks like we won't quite make the target, but there has been a lot of progress.

The UN special envoys report is here. Under-five deaths worldwide declined from 12.7 million in 1990 to 6.3 million in 2013, that's about half -- and of course the population and total number of young children has increased. Still, it looks like we'll wind up about 1.6 million short of MDG 4. The highest rates are in Africa and some countries in Asia. Of course civil conflict is an important factor in failure to make the targets -- particularly noteworthy are the Democratic Republic of Congo, Nigeria, and Pakistan.

The empowerment and education of women, and access to contraception, are key to reducing deaths of newborns. The Guttmacher institute estimates that giving all women and their newborns comprehensive sexual and reproductive health services would reduce deaths of newborns by 77%, at a cost of $25 per woman per year. Maybe that's why the anti-abortion activists don't care to invest in saving babies.

Wednesday, February 18, 2015

The not always reliable but reasonably on target this time Matthew Yglesias offers four ways to improve health care in the U.S. and, oh yeah, actually save money at the same time. His first idea is to admit more foreign M.D.s to practice in the U.S. I do have a correction -- we don't have a shortage of doctors, we have a shortage of primary care physicians. If we're going to let more furriners in, they should be primary care docs. Right now, it's very difficult for non-U.S. citizens to get working papers, and to get licensed. We could make it easier. However, Yglesias's idea that they would work for lower salaries doesn't sound very viable. They'd have to get paid like everybody else.

He also recommends that more states allow Nurse Practitioners (and I would also say Physician Assistants) a wider scope of practice. They can do most of what primary docs do, they are paid less, and they are a lot less costly to train. We could expand the supply of primary care providers fast if we allowed more of these "physician extenders" to practice.

He also wants to change the patent rules so that drug companies don't get such extended monopolies, which would bring down prices. Actually his idea of awarding prizes for new drug development isn't that great -- we should have publicly funded drug development, which would allow us to aim the research at meeting public health needs, instead of profit. Then the government would license the new pharmaceuticals to manufacturers for a reasonable fee, requiring them to limit themselves to a reasonable profit.

Finally, he wants all-payer rate setting. It's a bit wonky, but it basically accomplishes some of the cost savings of a single payer system. It still leaves the insurance companies in the middle as useless parasites, but that's probably the best we can do.

Monday, February 16, 2015

Republicans are giddy over the prospect that the Supreme Court will ignore facts, logic and precedent and invalidate subsidies for people who purchase health insurance on the federal exchange. Funny thing -- New Kaiser health tracking poll finds that if that happens, 64% of the public wants Congress to pass a law restoring eligibility for subsidies. And 59% think their state should establish its own exchange.

And yet, 46% say they view the act unfavorably, compared to 40% who view it unfavorably. People don't like the law, but they like everything that's in it. Explain it to me.

Friday, February 13, 2015

Heard much about the ACA open enrollment period this year? Probably not, and that's because it's been going just fine, thank you, and if it doesn't bleed, it doesn't lead. Sayeth Rachan Pradhan at Politico, "Obamacare enrollment ends Sunday night, and all signs point to the White House easily meeting its 2015 targets. The
signup season has unfolded so smoothly — so unlike the bumpy drama of
the first season— that Americans have scarcely noticed."

Well, how can they notice if the corporate media won't report it? No, the ACA isn't perfect -- that would be universal, comprehensive single payer national health care. People who make too much to qualify for subsidies, and who are healthy, are likely to find non-group insurance a pretty expensive product for something they probably won't use. And yeah, getting them into the pool is very helpful for making the finances work. But still, enrollment of low risk people is good enough.

It's still going to take another year or two for people to figure this thing out and for the late adopters to show up; and with Congress unwilling to fix problems, there are still some people who fall through the cracks. It's never going to achieve universal coverage. But it's better than what we had before, and I can't believe that in time, most people won't come around to seeing that.

However, they need the corporate media to be as interested in reporting success as they are in reporting failure.

Wednesday, February 11, 2015

An interesting essay in JAMA today by Marc Garnick, which I believe you cannot read because you are mere common rabble. So I'll tell you what it says, or at least a simplified version.

In between the ads for CTCA, which I discussed yesterday, you may see ads touting the horrors of "Low T," a "disease" that purportedly afflicts men as they age and which leaves them weak, tired and limp of member (if you know what I mean). You may separately see commercials touting specific testosterone products.

So here's the real deal. Testosterone as a medication was approved for people who had disorders of the testicles or pituitary (which stimulates the testicles to produce testosterone). If you really aren't making testosterone, yes you have a problem. However, it is normal for testosterone levels to fall as men age and there is no evidence whatsoever to support any benefit from testosterone replacement therapy (TRT) in such normal aging. An FDA advisory committee recently also found that there are indications of possible cardiovascular risk from testosterone "therapy." The committee voted 20 to 1 in favor of limiting the indication for TRT to people with classic hypogonadism, adding a statement about cardiovascular risk to the label, along with a statement that safety and efficacy of TRT in age related hypogonadism has not been established.

So what's going on here? From just 2010 to 2013 the number of prescriptions for TRT in the U.S. increased by 1 million. The drug industry invented a fake disease; used television advertising to persuade the public, including physicians, that it exists; and then started selling products to treat it. They could do this because the ads that just try to convince you that the disease of Low T exists, which don't name a specific product, aren't regulated by the FDA.

When TRT is legitimately used, guidelines call for initial assessment of testosterone levels, which have to be below a certain value; and continued monitoring during treatment. But many men who receive TRT have no claim for a testosterone test on their insurance record.

Tuesday, February 10, 2015

If you share my vice of sometimes watching sports on TV, you have been afflicted with advertisements for Cancer Treatment Centers of America. I was inspired to write this post just by looking at the ads. I can't evaluate the quality of whatever actual cancer treatment they provide, but they do not inspire confidence by aggressively promoting quackery and fraud.

One of their ads features a naturopathic "doctor" describing all the wonderful things she does for her patients. Naturopathic "training" consists of exposure to every form of nonsense known to humanity, from homeopathy to acupuncture to ayurvedic and traditional chinese medicine, plus energy therapy and anything and everything else that is preposterous. They then use these indiscriminately depending on their personal whims. Naturopathy is completely worthless.

Here's why. Because Louisiana refused the Medicaid expansion. Prior to the ACA, hospitals that served large numbers of uninsured people, who otherwise would have had to eat the cost, got extra federal money. (Called Disprportionate Share, or DISH payments.) But with the ACA, all those poor people were supposed to have Medicaid, so DISH wouldn't be needed after all, hence it was greatly reduced.

But in Louisiana, they don't have Medicaid after all. So the hospitals are in the doo doo. And this is all because Bobby Jindal is so smart.

Thursday, February 05, 2015

Sorry for the sucky blogging of late, coping with the weather and the challenges of continually removing snow from my 3/8 of a mile driveway has taken it out of me.

Anyway, the title of this post refers to Tennessee's Republican legislators, who wouldn't even take a vote on Republican governor Bill Haslam's plan to expand Medicaid under the Affordable Care Act. He had negotiated what's called a waiver with the Center for Medicare and Medicaid Services which included various stuff that conservatives like such as cost sharing by recipients and incentives for people to engage in healthy behaviors. The hospital association agreed to take on the state's share of costs so it wouldn't cost the state a penny.

But apparently the very idea of giving people health care is evil because of freedom. I got a press release from a wingnut group claiming the following:

“This
is a great day for Tennessee and it’s a signal to all of the other
legislators in states considering expansion that you can stand up for
the people of your state,” said Tarren Bragdon,
FGA CEO.

“Insure
Tennessee would have been nothing short of a disaster for Tennessee’s
taxpayers, patients, and healthcare system. We saw time and again in our
polling and our work in the state
that the people didn’t want ObamaCare expanded there. We are so proud
to see the legislature stand up to a conservative governor trying to
push the left’s agenda.”

That's right. Health care for the working poor would be a disaster for them. I'm not getting why, are you?

Friday, January 30, 2015

This is extremely disgusting. Doctors in California, who receive payments and other benefits from drug companies, have been prescribing anti-psychotics to kids in foster care -- kids who are not psychotic at all, but who are being drugged into a stupor in lieu of properly addressing their behavioral problems. According to the investigation by the San Jose Mercury News, drug companies spent $14 million from 2010 to 2013 to bribe doctors into making these prescriptions.

According to the investigation, nearly 25% of California foster children age 10-18 were prescribed antipsychotic drugs. I have written about these drugs here before. They are extremely toxic and can cause weight gain, diabetes, and other severe side effects. They are appropriately prescribed only as a fairly desperate measure for people who suffer from psychoses -- schizophrenia and severe bipolar disorder. Some kids were on as many as 8 psychiatric medications; and at most they would be appropriate for fewer than 2% of children. (None, in my opinion. These psychoses are generally not diagnosable until late adolescence and putting any such label on a child, whose brain is still developing, is wrong.)

Tuesday, January 27, 2015

I have discussed initiatives in the Affordable Care Act that encourage experimentation with new ways of reimbursing health care providers --Accountable Care Organizations being the most noteworthy. These are capitated (i.e. paid a lump sum per year per patient, with some adjustments) multi-specialty provider entities that get bonuses for patient satisfaction and good outcomes and get their pay docked for bad outcomes. But, these are just experiments that will only have a few takers.

But now the Administration has announced a major change in Medicare. By then, 30% of payments will be under ACO-like alternative pay models. A total of 85% of Medicare payments will be tied to outcomes in some way by 2016. Right now, most doctors are paid to do stuff, which means they do too much. They are paid even more if the stuff they do actually harms you and you need more care to fix it. (That happened to me: I underwent a right hemicolectomy, leading to what would be more than a hundred thousand in current dollars, when all I had was diverticulitis.)

We'll see if this really happens, and how well it works. But it's a revolution.